Forward thinking

How Boots employed the business principles of MFV to add
value to its occupational health service.By Sheila Collins

Many occupational health professionals promote OH as a
service that will be more use to its employer if it operates proactively rather
than reactively. If more time were given to staff welfare at work, then less
time would be needed to deal with the consequences of ill-health1.

An example of a reactive function is the treatment service.
This facility usually comprises of a walk-in surgery which employees can attend
with any health problem. This may be a useful means of detecting work-related
health problems, but the treatment service also attracts less appropriate cases
such as those where the condition is self treatable, or needs the attention of
a GP.

OH nurses believe that reducing minor treatments to allow
more time for minimising work-related ill-health will save money for the
company2, and improve the health and wellbeing of the workforce. The challenge
is to prove this to the employer who is asking OH to demonstrate where they add
value3.

Re-educating the workforce

As a nurse working in occupational health for Boots in the
East Midlands, I work as part of a team providing a treatment service to the
headquarters site staff. However, our service is now only accessed by a
minority of employees because we chose Managing For Value (MFV) as our tool to
promote the OH service. Through MFV we have dramatically reduced inappropriate
attendances by re-educating all levels of the workforce. As a result, we are
able to direct more of our efforts and skills towards minimising work-related
ill-health.

Managing For Value – originally named Value Based Management
– is a "systematic approach to managing companies to achieve the governing
objective of maximising wealth creation and shareholder value over
time."4. It is a management tool to generate the greatest wealth for
shareholders, which is how a company’s success is measured.

MFV is not only a tool but also a philosophy at Boots. It
encompasses a set of principles that are used to approach strategic business
planning, guide decision making at all levels and identify where value can be
created. "Value" should not be confused with cost. MFV is not driven
by the monetary worth of an idea or service, but by its benefits and how they
might increase the wealth of the company’s shareholders in the long term. For
example, if a company were to launch a new product, MFV would consider the
initial cost of the launch, but not be constrained by it. All the options
relating to cost, alternative products, markets, advertising etc would be investigated,
and an eclectic option likely to give the greatest return selected.

Under its original name, MVF was created by an American
consultancy and engaged by Boots in 1991, being one of the first UK companies
to do so. It was introduced to the company’s occupational health service in
1997 and now drives its strategy. MFV principles have been successfully applied
within the treatment service which previously attracted a high number of
inappropriate attendances, and compromised preventative care.

Past failings

Past attempts at reducing inappropriate attendances had
failed in several ways:

– Predecessors among the nursing staff had promoted a nanny
service. They wanted employees to feel cared for and consequently tended to
their every need. Indeed, OH was a company perk

– OH devised a leaflet encouraging employees not to attend
with non work-related conditions and distributed it throughout the site. It did
not work. OH had acted in isolation. We only considered what was value
destroying to us and not to the company. We did not consult with our managers
in person to listen to their needs

– Placement of the nurses around the site within certain
factories and warehouses for a few hours per day had the opposite effect of
that hoped for. We had made ourselves even more accessible and therefore only
encouraged employees to attend with non work-related ailments. It also required
more nursing and medical support staff.

Three-tier system

Lessons had been learnt from these failed attempts, but the
fact remained that the quality of the occupational health service was still
being jeopardised due to the high demand of customers attending with minor
ailments. Enter MFV.

First we reviewed our current situation within the treatment
service and the value content of each component. A three-tier system existed:

1 An on-site treatment service to approximately 8,000
employees at the headquarters site in Nottingham. This is a walk in service
between 08.00 and 16.45 Monday to Friday and is staffed by qualified and non
qualified OH nurses. Work related and non work related cases are seen. First
aid cover is available throughout the site for out of hours incidents

2 An on-site service to fewer employees based off-site
but within the Nottingham area. Very few off site personnel attend.
Occasionally telephone advice is required.

3 No treatment service provided to approximately 70,000
employees based outside Nottingham and throughout the country.

Nursing Adviser time was allocated to run the service but
little or no control was allowed as an appointment system was not used except
for repeat treatments and referrals. Medical support staff were also required
to work reactively.

A breakdown of surgery attendances showed that only 20 per
cent were work related. The other 80 per cent was made up of minor ailments or
conditions that should have been treated by a GP.

From our customer survey we learnt that people felt we
provided a professional service but they did not really understand what our
main role within the company was, and could therefore be forgiven for thinking
that we were in some ways a substitute GP service. They liked having ease of
access and not having to make an appointment.

The service at that time added value because work-related
health problems were seen that would otherwise not be detected during the
nurses’ normal workplace activities, and employees spent less time away from
work by not having to go elsewhere for treatment. Little value was achieved,
however, for OH or the employer, by using qualified nurses to treat non
work-related problems, particularly where employees could self-treat.

It was clear that the service needed to be restructured but
more importantly, occupational health needed to develop active partnerships
with management and employees that would agree the needs of the customer, and
market OH services.

We put forward possible options for improving the value of
the treatment service:

Option 1 – a restricted treatment service

An appointment system would be encouraged and the hours
restricted. This would coincide with health promotion activities that aim to
educate management and employees about self care. Occupational health time
would be pre-planned and reactive time would be reduced considerably. Work
accidents and emergencies would always be seen immediately.

Employees would recognise the role of OH but still be
assured access to health professionals if problems arose. Some employees may
continue to want the service available to them all day because they can’t or
don’t understand the role of the service.

Value is created by allowing better use of nurses’ time for
proactive work and medical support staff time for pre-planning. Employees are
encouraged to take more responsibility for their own health, thus reducing the
time they spend away from work. An appointment system also allows management to
be aware of their employees whereabouts.

Option 2 – no treatment service

No service available. In this way OH time would be
completely dedicated to proactive work. This adds value because prevention of
ill-health at work will reduce costs to the employer. However, value may become
desolate if employees were to regard the occupational health service as
inaccessible and uncaring. There would be a tendency not to report work-related
health concerns.

In addition, the treatment of work accidents would be more
costly for the company if employees had to go to their GP each time, and there
would be less control over accidents if reporting was inadequate. GPs may not
always liaise with occupational health to discuss relevant cases and may even
lose respect for the department as their surgeries become overloaded.

Option 3 – an external OH service provider

This refers to outsourcing of the service. Again, permitting
more time for proactive work forms value, but an external provider without the
same knowledge of the company and with its own business financial interests
could conflict with the company’s needs.

Option 4 – disseminate the service into the workplace

We already knew from past experience that this would not
work.

Option 5 – rationalisation of the current service

Access to the service would remain the same, but an ongoing
programme of developing partnerships with the workforce would take place to
reduce inappropriate attendances. The programme would include presentations to
management about OH, highlighting the relationship between work and health, and
how by working together we can help them to manage and control work-related
ill-health.

Leaflets and other health promotion tools that offer
self-help advice, one-to-one advice given as people attend and group
presentations where necessary are also included. Management would be encouraged
to make appointments for staff to be seen in OH for non-urgent cases, rather
than relying on the walk-in route.

Taking action

This option showed the greatest potential to implement the
occupational health service key drivers, which are identified as sickness absence,
underperformance, staff turnover, ill-health retirement and medico-legal. More
time would be available for the nurses to be proactive and carry out activities
that target the key drivers such as risk assessment and control.

It provides the best opportunity to ensure continuing
contact between the service and employees that would not be likely if the
service was removed or restricted. Work-related health problems that could
otherwise go undetected would be treated appropriately and any trends investigated.

Since rationalisation began in 1999, the number of
attendances to the treatment service has fallen by 60 per cent. Fifty per cent
of attendances seen in 1999 were inappropriate, compared with 80 per cent in
1997. The greatest value was realised not by changing the service, but by
establishing OH within the company as essential to the business function.

The principles of MFV can be applied to any process,
service, task or decision within business however small or large the effect of
that process. A four-step procedure is used and includes factual information
where possible. Assumptions are also made.

1 Position assessment

This looks at all aspects of the current process by breaking
it down into its component parts. What is being provided and to whom? How much
does it cost? Who benefits? How much time and whose time is needed to run the
process? During the assessment it is necessary to determine customer perception
of the process by carrying out surveys, and to benchmark against other
companies.

At this stage, it should be possible to identify the
fundamental reasons for the process which are known as the key drivers.

2 Options formulation

Having identified the key drivers, what remains is a shopping
list of components that can be assessed individually for their value content
and either exploited or revamped accordingly.

3 Options evaluation

From the shopping list a component is chosen and assessed
for its value content by using steps 1 and 2. The options for that component
are considered. For example, what would be the consequences of completely
removing it? Should it be outsourced or would it be better to hand it over to
the business to manage it themselves? The options that capitalise on the key
drivers are chosen.

4 Strategy definition and implementation planning

A strategic plan is formed and used as the vehicle for
implementing and monitoring value through the key drivers.